Latent Tuberculosis Infection Diagnostic and Treatment Cascade among Contacts in Primary Health Care in a City of Sao Paulo State, Brazil: Cross-Sectional Study

Abstract

BackgroundDiagnosis and treatment of latent tuberculosis infection (LTBI) is a tool for global TB control, especially in close contacts. But data is scarce in high burden countries, under field conditions, including data on the benefits of LTBI management.ObjectiveTo analyze the LTBI diagnosis and treatment cascade among contacts in primary health care (PHC) services in São José do Rio Preto—SP, Brazil.MethodsCross-sectional design, conducted with contacts of pulmonary TB patients followed in all PHC services. Data was collected from May to September 2014 in the Reporting System for TB cases (TBWEB) and Reporting System for Chemoprophylaxis. Medical records and treatment follow-up forms were reviewed and all the nurses responsible for TB in PHC services were interviewed.ResultsAmong 336 contacts included, 267 (79.4%) were screened for TB or LTBI, according to the presence or not of respiratory symptoms. Among those contacts screened, 140 (52.4%) were symptomatic, 9 (3.4%) had TB disease, 106/221 (48%) had positive TST result, meeting the criteria for LTBI treatment, and 64/106 (60.4%) actually started it. Overall, among 267 screened, only 64 (24%) started LTBI treatment. The completion rates of treatment among the contacts who started it, those with positive TST result and those screened were 56.3% (36/64), 16.3% (36/221) and 13.5% (36/267), respectively. Nurses claimed that asymptomatic TB contacts pay no attention to preventive health care and do not seek medical care as they do not have symptoms of the disease. In reviewing the medical records, high proportions of contacts without evaluation, incomplete assessment, incorrect records of contraindication for LTBI treatment, lack of notes regarding the identification and evaluation of contacts were identified.ConclusionsThere is a need for better organization of the surveillance and investigation routine for contacts in PHC, considering the reorganization of the work process and the features of the local health system.

Tuberculosis: renewed challenge in Brazil

“…Recently, clinical and operational research have indicated that the approaches are more effective when they respond to local socio-cultural characteristics, organization of health service delivery, and type of community activities. These approaches should cover the cascade of actions that include local TB transmission control, screening, and diagnostic investigation of active and latent TB, followed by its antimicrobial treatment, incorporating biomedical approaches [9][10][11][12][13] , biopsychosocial 8,14 , strengthening social protection 15,16 , community participation 17 , and political commitment 18 . However, in high TB burden countries, operational research performed to cover such approaches are limited.…”

“…Then, the use of new technologies may be incorporated to the National or Regional Clinical Guidelines [12][13][14]19,[35][36][37] . In recognition to these challenges, the World Health Assembly in May 2014 approved the new Global TB Elimination Strategy with a set of ambitious targets, later included in the Sustainable Development Objectives 2030 38 .…”

Conceptualizing Care Continua: Lessons from HIV, Hepatitis C Virus, Tuberculosis and Implications for the Development of Improved Care and Prevention Continua

“…Similarly, continuum models are also proving valuable in identifying gaps and focusing resources for HCV, TB, and other services (5, 11, 29). Analyses of the TB continuum led to the observation that non-adherence to TB treatment was one key obstacle to effective completion of TB treatment (30); directly observed therapy for TB was developed in response to this observation to address treatment adherence, to promote progress through the TB continuum and reduce the development of acquired resistance, and to reduce ongoing transmission (31, 32).…”

Effects of Programmatic Interventions to Improve the Management of Latent Tuberculosis: A Follow Up Study Up to Five Months After Implementation.

“…Previous studies of the cascade of LTBI care in Brazil had also demonstrated the highest losses in the initial steps (identi cation and investigation). (12,13) As mentioned by HCW in the questionnaires, interventions such as training, TB booklet and in-service training helped improve contact identi cation and treatment initiation. Notwithstanding, HCW also mentioned that clinics are understaffed and have a high demand from the public, which may have limited the capacity for contact identi cation once the intervention trial ended.…”